Primary Care Coding Alert

Question: One of our providers removed a 1.5 cm inflamed seborrheic keratosis from a patient’s arm using a 15 blade to shave the lesion at the skin surface. He described the procedure as a shave biopsy and coded it with 11302. I think he is wrong and want to code it as 17110 or 11102. Which of us is right?

AAPC Forum Participant

Answer: Your confusion is understandable, given your provider’s use of the phrase “shave biopsy.” However, based on the details you provided, your suggested use of 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) or 11102 (Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion) in this particular situation would be incorrect.

Code 17110 would be incorrect as the procedure involved removing the lesion with a blade, not destroying it with a chemical agent or scraping it with a surgical curette, which are the procedures highlighted in the code descriptor. Code 11102, though it does describe shaving, would also be incorrect as the descriptor suggests the purpose of the procedure was to biopsy the lesion and not remove it.

Instead, your provider’s use of 11302 (Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm) is correct, as the procedure describes removal of the lesion, which is what your provider intended and performed. Per CPT^®, “shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision.”

The fact that 11302 does not mention a biopsy does not preclude using the code, as CPT^® guidelines clarify that “during certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported.”

However, before submitting this claim, you will need to verify the actual technique used. This will ensure you are using the correct code.